Healthcare Provider Details

I. General information

NPI: 1548580707
Provider Name (Legal Business Name): SUSAN BOEHRER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 RIDGECREST RD
EDMOND OK
73013-6653
US

IV. Provider business mailing address

1692 E REDBUD RD
WASHINGTON OK
73093-9285
US

V. Phone/Fax

Practice location:
  • Phone: 405-203-7898
  • Fax:
Mailing address:
  • Phone: 405-426-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: